jmj11 Posted October 4, 2013 Share Posted October 4, 2013 I have my opinion on this situation but wanted to see yours. You see a brand new patient who reports to you a severe headache that came on after a spinal tap a month ago. It was positional at first but now constant and severe. To cut to the chase, you are concerned about a persistent CSF leak. You order a targeted blood patch through anesthesiology. As the patient is leaving they explain that their PCP has started them on morphine and you need to re-write it. To which you explain that you don't treat low pressure headaches with morphine, but do give them a step down narcotic for a taper. The next thing that happens is that they no show their appointment with you. You inquire about their blood patch and hear they no-showed their blood patch twice and had rescheduled it again (it is now a month later). So you ears perk up, you take the 30 minutes that it takes to log in and get the patient's state narcotic data base. To your horrors you find out that not only have they been on high doses of narcotics for over 14 months (which they didn't report) but they got morphine two days after they saw you and signed a narcotic contract. So, you dismiss them, sending them certified letter and etc. Now, the blood patch people call and say that the patient is still on their books for the patch (under your order). What would you do? Link to comment Share on other sites More sharing options...
Gaijyn Posted October 4, 2013 Share Posted October 4, 2013 I believe I would cancel my order for the blood patch. If possible I would attempt to get a hold of the pt's PCP (assuming he gave you the correct one) and update them on the situation, your concerns, and the reason why you can no longer treat the patient. Then, if the PCP or whoever is currently treating the patient felt the need for the patch or agreed with the possibility of a CSF leak they could address it however they felt most comfortable be it blood patch or otherwise. My reasoning for this is that you have already dismissed the pt from your practice, with good reason, and by what appears the most efficient and legal way. Thereby releasing yourself from the treatment of the patient. By maintaining your order, if the patient received the procedure after the dismissal, you would have reversed your stance and now would be treating the patient again by default. However, by contacting the PCP (again assuming it was the correct one and not a bogus PCP) and advising him/her of the situation, you have done the right thing by the patient in that you attempted to ensure they got the proper care. Further, I would think this would protect you legally in the advent of some negative outcome. I am still young to the profession but above is what I would do. If I misstepped or did not see something someone please correct me. Link to comment Share on other sites More sharing options...
jmj11 Posted October 4, 2013 Author Share Posted October 4, 2013 I believe I would cancel my order for the blood patch. If possible I would attempt to get a hold of the pt's PCP (assuming he gave you the correct one) and update them on the situation, your concerns, and the reason why you can no longer treat the patient. Then, if the PCP or whoever is currently treating the patient felt the need for the patch or agreed with the possibility of a CSF leak they could address it however they felt most comfortable be it blood patch or otherwise. My reasoning for this is that you have already dismissed the pt from your practice, with good reason, and by what appears the most efficient and legal way. Thereby releasing yourself from the treatment of the patient. By maintaining your order, if the patient received the procedure after the dismissal, you would have reversed your stance and now would be treating the patient again by default. However, by contacting the PCP (again assuming it was the correct one and not a bogus PCP) and advising him/her of the situation, you have done the right thing by the patient in that you attempted to ensure they got the proper care. Further, I would think this would protect you legally in the advent of some negative outcome. I am still young to the profession but above is what I would do. If I misstepped or did not see something someone please correct me. I agree and that is exactly what I did. The PCP is considering if she (first year PA) wants to do it our not. None of my business now. Link to comment Share on other sites More sharing options...
Gaijyn Posted October 4, 2013 Share Posted October 4, 2013 Good to know that my ethical compass (and legal one for that matter) is pointed in the right direction. Hopefully, she makes the right decision, whatever that is. Narcotics abusers are tough, one the one hand they are a drag on my time and resources better spent on those that truly need my help. On the other, they may actually have something wrong with them and it is dismissed because they "cry wolf" so many times.... At least you did the best thing you could and removed yourself from what will probably be a messy situation. Link to comment Share on other sites More sharing options...
Moderator True Anomaly Posted October 4, 2013 Moderator Share Posted October 4, 2013 It's quite easy to say now that you told us what you did, but I would've done the same thing. You did your due diligence, so it's adios mi amigo. Link to comment Share on other sites More sharing options...
ToppDog Posted October 4, 2013 Share Posted October 4, 2013 Interesting case. I have a couple questions: 1. Were any new patient medical records obtained to verify the patients story of having the final tap? 2. How many days have passed since you sent the certified letter discharging the patient? 3. If you are still within the 30 day window required by law, what legal issues may arise from cancelling the blood patch before he can arrange to have care transferred elsewhere? Link to comment Share on other sites More sharing options...
Moderator ventana Posted October 5, 2013 Moderator Share Posted October 5, 2013 I take a different course on these patients.... I separate the narcotics prescribing and medical care Just last last month I got "dupped" into giving a script on a new patient (I always try to believe them, but am at the same time suspicious) First time in about 2 years... anyways, I have had a few meetings since with this patient, and family, to explain that he is displaying addict behaviors, and he admitted to being dependent and an addict. I have kept him as a patient but have clearly stated and documented that I will not write any controlled substances to him. It is his choice if he remains my patient and to date he has keep me invovled. BUT this is not typical, usually once explaining that they have violated the patient provider relationship of trust around controlled substances I offer them to stay on as a patient with out any possibility of narcotics or benzos and they pretty much all find another provider. They essentially fire me, instead of me firing them. In your case I would have requested an office visit, booked out 20 min to counsel them on controlled subs, presented to them the option of remaining a patient..... let them choose, and have a DX in the chart that they have a narcotic dependency/addiction. If and only if they do this would I continue to allow the blood patch to be done. Till then I would suspend/cancel it. This way you are not taking options away from the patient, but instead allowing them to choose. PS - I would also give anyone I referred this patient to an informal heads up to no give any controlled substances...... (unless TANGIBLE proof of pain, ie fracture) Link to comment Share on other sites More sharing options...
primadonna22274 Posted October 5, 2013 Share Posted October 5, 2013 Cancel it. It's palliative, not mandatory and the patient has already been noncompliant for f/u twice and lied to you. Your ethical obligation to the patient is to fulfill the 30-days EMERGENCY treatment only and a blood patch is not emergent. Don't lose any more sleep on this patient. Link to comment Share on other sites More sharing options...
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